Can social prescribing provide the missing link?
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Primary Health Care Research & Development 2008; 9: 310–318
doi:10.1017/S146342360800087X
Can social prescribing provide the missing
link?
Jane South1, Tracy J. Higgins2, James Woodall1 and Simon M. White2
1
Leeds Metropolitan University, Leeds, UK
2
Bradford & Airedale tPCT, Bradford, UK
Background: The voluntary sector has long been recognised as making an important
contribution to individual and community health. In the UK, however, the links
between primary health care services and the voluntary and community sector are
often underdeveloped. Social prescribing is an innovative approach, which aims to
promote the use of the voluntary sector within primary health care. Social prescribing
involves the creation of referral pathways that allow primary health care patients with
non-clinical needs to be directed to local voluntary services and community groups.
Such schemes typically use community development workers with local knowledge
who are linked to primary health care settings. Social prescribing therefore has the
potential to assist individual patients presenting with social needs to access health
resources and social support outside of the National Health Service. Aim: The aim of
this paper is to explore the concept of social prescribing and discuss its value as a
public health initiative embedded within general practice. Methods: The rationale for
social prescribing and existing evidence are briefly reviewed. The paper draws on
a case study of a pilot social prescribing scheme based in general practice. Data
collected during the development, implementation and evaluation of the scheme are
used to illustrate the opportunities and limitations for development in UK primary
health care. Findings: The potential for social prescribing to provide a mediating
mechanism between different sectors and address social need is discussed. The paper
argues that social prescribing can successfully extend the boundaries of traditional
general practice through bridging the gap between primary health care and the
voluntary sector. The potential for wider health gain is critically examined. The paper
concludes that social prescribing not only provides a means to alternative support but
also acts as a mechanism to strengthen community–professional partnerships. More
research is needed on the benefits to patients and professionals.
Key words: general practice; social needs; social prescribing; voluntary sector
Received: 7 March 2008; accepted: 22 August 2008
Introduction public health agenda within the role of primary
care organisations, the core business remains
Public health and primary care in the UK have based on clinicians providing individual care and
been described as having a ‘necessary relation- treatment (Godinho et al., 1992; Department of
ship’ but one defined by its complexity (Busby Health, 2002; Peckham and Exworthy, 2003;
et al., 1999). Notwithstanding drives to embed the Secretary of State for Health, 2006). While many
public health initiatives attempt to engage the
‘hard-to-reach’, general practice remains a key
Correspondence to: Jane South, Centre for Health Promotion point of access, including for those presenting
Research, Queen Square House, G08, Leeds Metropolitan
University, Leeds LS1 3HE, UK. Email: j.south@leedsmet. with social needs. Provision and utilisation of
ac.uk services is not necessarily indicative of the capacity
r 2008 Cambridge University PressCan social prescribing provide the missing link? 311
to meet health need. Despite the potential bene- with communities whose health needs are not met
fits, voluntary sector support often remains by mainstream services. One major challenge for
underused because links between health services public health is developing effective partnerships
and community organisations are weak or non- to harness voluntary sector resources within
existent. Social prescribing is a new approach in communities, thereby improving access to the
primary care, which promotes the use of the range of support available.
community and voluntary sector. It is generating Social prescribing has emerged as a mechanism
interest as an approach that can bridge the gap for linking people using primary care with sup-
between health services and health needs through port in the community (Brown et al., 2004). The
signposting and support. The aim of this paper is gap between primary care and voluntary organi-
to explore the concept of social prescribing and sations is bridged through community develop-
critically examine its value as a public health ment workers who have detailed local knowledge,
initiative embedded within primary care. The thereby ensuring appropriate signposting for
paper draws on a case study of the development individuals (Bromley NHS Primary Care Trust,
and evaluation of a social prescribing scheme to 2001). Friedli and Watson (2004) suggest that
reflect on the opportunities and constraints in social prescribing has benefits in three key areas:
developing this type of initiative. improving mental health outcomes for patients,
improving community well-being and reducing
social exclusion. The point here is that putting
The rationale for social prescribing individuals in touch with local voluntary organi-
sations and groups has the potential to impact not
Health service resources are under increasing only directly on mental and physical health
pressure in the UK and it is envisaged that but also indirectly through increased social con-
voluntary organisations, as part of what is termed tacts, improved access to services and ultimately
the third sector, will play an increasing part in the improved social networks within communities.
provision of primary care services (Coid et al., Brown et al. (2004) comment on the relevance of
2003; Department of Health, 2004; Secretary of this to disadvantaged and vulnerable groups who
State for Health, 2006). Voluntary and commu- might normally face barriers to service use.
nity organisations complement statutory services Social prescribing is a relatively new concept
by responding to local needs informally and by with only a small number of schemes in UK
filling service gaps (Ward, 2001; Milne et al., 2004; practice and as such there is a limited evidence
Secretary of State for Health, 2006). This can base (Brown et al., 2004). A randomised con-
include both the provision of health informa- trolled trial of the Amalthea Project (Grant et al.,
tion and support services by national organisa- 2000) examined general practice patients with
tions through to small scale local activity such as psychosocial problems given access to voluntary
self-help groups or community-based social organisations. At one and four months after ran-
activities, for example, luncheon clubs and walk- domisation, those assigned to the intervention
ing groups. Crombie and Coid (2000) suggest that group had significant improvements in anxiety,
given the range of voluntary organisations, there improved ability to carry out everyday activities
is likely to be one to help every patient presenting and improved feelings about general health and
in the National Health Service (NHS). They note quality of life. Another study found that a
that support organisations exist for a host of rarer voluntary referral scheme had successfully uti-
conditions as well as for the major disease groups. lised the voluntary sector to support patients. The
Voluntary sector provision is generally rooted in scheme was reported to be an important adjunct
values such as empowerment, promoting rights to traditional approaches of referral in general
and engaging with people on their own terms practice, acting as: ‘a linchpin between the pro-
(Wakeling, 1999). Such a provision can fulfil a fessional role of medicine and the voluntary
vital role in addressing public health issues world of psychosocial support’ (Faulkner, 2004,
through education, advocacy and support. This p. 46). Likewise, comparable referral and sign-
has particular significance in the context of health posting schemes based in general practice have
inequalities where voluntary organisations work been shown to be effective at addressing social
Primary Health Care Research & Development 2008; 9: 310–318312 Jane South et al.
needs (Clarke et al., 2001; Aylward and James, Box 1 Examples of groups and services
2002). used by CHAT
The benefits for individuals when access to
support is facilitated are evident; however, it can Luncheon clubs
be argued that such mechanisms result in the Befriending groups
transfer of service users to other sectors, thereby Social services
shelving underlying problems. This in turn raises Volunteering organizations
questions about whether social prescribing repre- Getting back into work groups
sents a ‘joined up’ solution to social issues seen Literacy classes
in primary care or is it merely a ‘bolt-on’ to pre- Debt advice
dominately clinical services. The significance of Access bus
social prescribing as a mediating mechanism Bereavement groups
between different sectors will now be explored in Reminiscing groups
a case study of the development and imple- Arts and craft groups
mentation of one scheme. Music groups
Social prescribing in practice – a case
study alternative statutory services (see Box 1 for
examples). The worker may accompany clients
The Community Health Advice Team (CHAT) on their first visit in cases where clients lack
is a social prescribing scheme established by confidence or require additional support. There is
Bradford South and West Primary Care Trust one follow-up appointment to check on the pro-
(PCT) in 2005. The aims of the scheme were to gression of the client and ascertain their views
broaden service provision for patients with non- on the organisations visited. The CHAT worker
clinical needs and to facilitate links between liaises with health professionals as required and
primary care and the community and voluntary sometimes meets with referrers to the discuss
sector. A CHAT worker, with community develop- management of client needs. At the end of the
ment experience, was appointed to develop and process, the referring health professional is given
deliver the scheme in two general practices both a written account of what has taken place and
located in disadvantaged urban areas. The scheme what services the patient has been offered.
has since been extended to a third practice. In
relation to the referral process, patients either
refer themselves, via a tear-off slip on leaflets that Methods
are on display in the surgery or local pharmacies,
or are referred by general practitioners and other The case study emerged from a process of
practice staff including practice nurses, health co-operative enquiry that sought to deepen the
visitors and receptionists. The health profes- understandings of how and why social prescribing
sionals complete a simple referral form that asks worked in this context (Reason and Heron, 2004).
for contact details, the reason for referral and A formative evaluation, undertaken by two of the
who the referrer is. The client is then contacted authors (Woodall and South, 2005), was part of that
within seven days to arrange an appointment. process. Qualitative methodology was used for the
Although people are encouraged to come to their evaluation in order to understand how the scheme
local general practice surgery, it is possible for operated within a specific social context and to
home visits to be arranged. Up to three appoint- examine the acceptability and relevance of the
ments of approximately up to 40 min each are scheme (Patton, 1987). Semi-structured individual
held with clients to discuss their needs and to then interviews were undertaken with 10 clients and
identify an appropriate source of local support. eight health professionals. Clients were purposively
The CHAT worker facilitates access to local sampled from a database of individuals who had
organisations, predominately from the voluntary participated in the CHAT scheme and had expres-
and community sector and also including some sed an interest in contributing to an evaluation of
Primary Health Care Research & Development 2008; 9: 310–318Can social prescribing provide the missing link? 313
the service. The construction of the sampling frame recognised that health professionals were not
reflected the diversity of CHAT clients in relation signposting patients because they were unaware
to their gender and age as well as to their frequency of the breadth and variety of available services.
of service use and complexity of need. Clients Learning from another scheme indicated that
who were selected were contacted to discuss the social prescribing was more effective with a
evaluation and the possibility of participating in a dedicated worker based in general practice, as
confidential interview with a member of the opposed to being managed and delivered exter-
research team. Individuals who declined to parti- nally (Bromley NHS Primary Care Trust, 2001). It
cipate at this point were thanked for their time and was therefore agreed that the CHAT worker
additional clients were then re-sampled. would be part of the PCT Public Health Team
Health professionals were selected on the basis but be based, at least for a proportion of their
of their professional role, their experience of working week, in the pilot practices.
the CHAT service and the number of referrals Participating practices were involved in
made. All health professionals who were selected recruitment and selection; however, this process
to take part in the evaluation accepted. The exposed differences in the models of health
composition of the health professional sample valued by individual panel members. The CHAT
included three general practitioners, two practice worker was required to have good knowledge of
managers, two nurse practitioners and a healthy- the voluntary sector and of community develop-
living centre co-ordinator. All interviews were ment principles and practice. These qualities are
taped, transcribed and analysed thematically. A very different from those traditionally valued
small number of anonymous quotations derived in primary care but eventually a common under-
from the evaluation are used in the paper to standing of the purpose of the scheme was forged.
highlight discussion points. In addition, monitor- Individuals representing the practices later
ing data on client characteristics and social need became champions of the scheme, which led to a
covering the first 15 months of operation smooth implementation and early integration of
(between May 2005 and October 2006) are also the worker into the primary health care team.
presented. The categories were developed induc- The evaluation later found that health profes-
tively; presenting issues were categorised by the sionals felt comfortable referring patients due to
social prescribing worker based on the initial high levels of trust and confidence in the CHAT
assessment of the client. As part of the colla- worker’s ability to find appropriate voluntary
boration, structured discussions were held with services. Sherratt et al. (2000) suggest that spe-
the public health manager and the social pre- cialist advice workers are appreciated as they
scribing worker over the course of the scheme provide a better service to patients and also save
development and detailed notes were taken. The staff time. Referring patients to a single known
paper focuses on three key issues that emerged person reassured clinicians that the referral would
through those discussions: be dealt with appropriately. One individual con-
trasted this to other external schemes where they
> How does social prescribing fit within primary
were referring people ‘into a black hole’.
care?
The issue of location is evidently significant for
> What is its contribution as a public health
social prescribing, not only for the primary health
intervention?
care team but also in terms of improving access.
> Can social prescribing form part of a strategic
The question of integration goes beyond the
approach to building links with the voluntary
challenge of providing a seamless service and
sector? touches on the extent to which alternative
approaches to health improvement can co-exist
Extending primary care (Levenson and Johnson, 2000). Our experience is
that social prescribing does not exacerbate con-
In 2005, the PCT was funding a small number of flict but instead extends traditional primary care.
local and districtwide voluntary and community One general practitioner described the benefits
organisations, but, in most cases, there were no as ‘having that extra something you can do for
connections to primary care services. It was patients’.
Primary Health Care Research & Development 2008; 9: 310–318314 Jane South et al.
There are enormous challenges for primary Reflecting on the CHAT experience, for some the
care in urban disadvantaged areas (Royal College initial appointment is all that is needed, as this
of General Practitioners, 2005), and research can give the necessary space for reflection as
indicates that health professionals are aware of individuals benefit from the process of being
the impact of poverty on health (Daykin and listened to and starting to voice their aspirations.
Naidoo, 1997). The CHAT scheme illustrates how It is not suitable for those who require an inten-
social prescribing can offer the opportunity to sive package of support and the limit on number
address social needs through individual con- of appointments prevents dependency. The eva-
sultations. An added bonus may be the reduction luation found that the longer appointment time in
of workload and more capacity to focus on med- comparison to clinical consultations was valued,
ical problems. Hence far from being about shift- as was the offer to accompany the client to a new
ing responsibilities and transferring so-called group. In the interviews, clients identified benefits
problem patients, we argue that social prescribing including social inclusion, feeling ‘part of some-
should be seen as one way of extending primary thing’, meeting new people through community
care through partnership working. groups and increased confidence. The case studies
in Box 2 illustrate the indirect and direct benefits
A public health intervention? gained from accessing community resources and
receiving low-level support through primary care.
A claim can be made that social prescribing, The prominence of psychosocial problems has
through addressing the wider determinants of been described as a ‘distinguishing feature’ of
health, represents a reorientation of health services, general practice (Brooke and Sheldon cited in
albeit one limited in scale and scope. A key ques- Gulbrandson et al., 1999) and social factors have
tion is the extent to which such schemes are able to
reduce health inequalities and improve access to
health resources. Monitoring data from CHAT Table 2 Presenting issues
demonstrate that the scheme is used by a wide Presenting issue Numbers (%)
range of people and it is noteworthy that there has
been success in attracting men and also younger age Social isolation 102 (45)
groups (Table 1). There is a spread of presenting Housing/benefits 35 (16)
Training 23 (10)
issues (Table 2), confirming the underlying demand Family issues 20 (9)
for support and advice services located in primary Volunteering 17 (8)
care (Greasley and Small, 2005). The majority of Feels useless 10 (4)
referrals came through health professionals; 37% Disabilities 9 (4)
Bereavement 7 (3)
through general practitioners and 38% through Exercise 2 (1)
nursing staff while only 18% were self-referrals. Total 225 (100)
Social prescribing aims to provide a holistic
package of support tailored to individual need. Source: Monitoring data, May 2005–October 2006.
Table 1 Social prescribing clients – age and sex
Age Female Male Total (%)
16–25 25 9 34 (15)
26–35 18 11 29 (13)
36–45 26 10 36 (16)
46–55 21 18 39 (18)
56–65 8 10 18 (8)
Over 65 40 13 53 (24)
Age not recorded 10 4 14 (6)
Total 148 (66) 75 (34) 223 (100)
Source: Monitoring data, May 2005–October 2006.
Primary Health Care Research & Development 2008; 9: 310–318Can social prescribing provide the missing link? 315
Box 2 Case studies of CHAT clients
A very elderly woman living on her own managed very capably. The only real problem was that her
eyesight was deteriorating rapidly and she loved to read. She had tried listening to taped books, but
she was missing company during the day and she liked to discuss the books she was reading. She was
put in touch with a befriending service and an arrangement was made that a volunteer would visit
once a week to read together. This arrangement was still continuing over 12 months later.
A young woman described being bored at home now that her two young children were both at
school. Ideally she wanted to get into work but had no qualifications. She was accompanied to a
local voluntary organisation where she met the staff and decided she wanted to do a basic IT course,
one half day a week. From this course she went to another, and with the help of the organisation,
she secured a job.
One elderly woman was very isolated at home. In the consultation with the CHAT worker it
became apparent that she used to love to dance but she very rarely left the house as she was quite
scared. A local community group was contacted and they agreed to pick her up one day a week, and
take her to their regular dance. The lady did not dance there, but she really enjoyed the music and
the company.
One man had a full time job but he was spending beyond his means and was so stressed about it that
he had been off work for several months. The CHAT worker arranged for him to see a local debt
adviser, who helped with his financial position. He continued to be seen by CHAT to re-build his
confidence. He returned to work and, in his own words, he ‘got his life back’.
been found to be associated with frequent atten- Social prescribing is based on a similar model
dance (Vedsted and Christensen, 2005; Zantinge to welfare benefits advice in primary care that has
et al., 2005). Busby et al. (1999 write: potential for increasing access to support and
advice within health service settings (Sherratt et
The difficulties and dilemmas inherent in al., 2000; Greasley and Small, 2005; Adams et al.,
understanding the full complexity of the 2006). Abbott (2002) critically examined the case
relationship between an individual patent, his for welfare benefits advice in primary care as a
or her biography and the wider circumstances health intervention. He argues that although
of history and economic change is faced most welfare benefits advice is likely to have a minimal
squarely by practitioners in primary care. impact on the environmental determinants of
community health, in this case poverty and
The limitations of clinical practice are illu-
deprivation, it should be valued because of the
strated by a general practitioner in the evaluation:
potential effect on the psychological status of
There’s no point fixing them up physically individuals through the reduction of anxiety and
and ignoring the housing benefit or the fact stress. He concludes that while the imperative to
they can’t read and write, and if I can’t fix it address health inequalities is paramount, primary
I want to be able to point them in the right care has a part to play. These conclusions can be
direction. applied equally to social prescribing. As an
intervention it does not address underlying pro-
Given the impact on practice, it would seem blems in communities, such as social isolation,
logical that primary care plays a part in addres- but it does mitigate the impact on individual
sing the wider determinants. The challenge health and enable people with social needs to
is how to incorporate a public health approach make positive choices. Signposting to local orga-
alongside the provision of quality, patient-centred nisations promotes community engagement,
care. which has additional benefits (Rogers and
Primary Health Care Research & Development 2008; 9: 310–318316 Jane South et al.
Robinson, 2004). The potential for wider health Social prescribing is dependent on the exis-
gain is due to the ‘distinctive value’ of the voluntary tence of a flourishing voluntary and community
sector in terms of the development of social capital sector. Crombie and Coid (2000) question the
and social networks in communities (Bolton, wisdom of portraying the voluntary sector as a
undated). Overall, we argue that the combination ‘white knight’ coming to the rescue. Variety in
of individualised support and linking to community terms of size, function, ownership and governance
resources makes social prescribing an appropriate and funding (Taylor, 1997; Social Services
public health intervention for primary care. Inspectorate, 2000) raises inevitable questions
about capacity and the level of strategic
funding and support needed from statutory
Building health alliances agencies. Although flexible, voluntary organisa-
tions have a degree of instability that can affect
‘Making Partnerships Work’ (Department of access and impact on support (Coid et al., 2003).
Health, 2004) promotes a deeper and more Quality and accountability issues may also be
meaningful engagement between the NHS and present (Johnson et al., 1998; Weir, 2002). In areas
the community and voluntary sector. Over 3000 where there is an absence of a strong community
voluntary and community organisations exist in and voluntary sector, such as some rural areas
Bradford district; part of the aim of the CHAT (Milligan, 1998), social prescribing may be inap-
scheme was to raise the profile of that sector and propriate.
to formalise and streamline patient introductions As with any approach that seeks to work across
to local organisations. One client spoke of how sectors, there are issues over commissioning,
participation on the scheme had ‘opened their management and provision. The CHAT model,
eyes’ to services in the local area: based in primary care but funded through public
I didn’t realise there was all these things that health, is only one of a range of possibilities.
were going on around me especially where I Social prescribing could potentially be provided
liveyit’s nice to know that there are things through community mental health services, social
like that available. services, in the voluntary sector or be delivered
within public health programmes. The onset of
There can also be an educational element in practice-based commissioning and social enter-
terms of increasing health professionals’ awareness prises (Department of Health, 2006, 2007) creates
and understanding of voluntary organisations. both threats and opportunities. There are also
A Royal College of General Practitioners brief- questions about how social prescribing fits with
ing (Royal College of General Practitioners, 2005, the new role of health trainers, lay people trained
p. 4) noted that ‘connecting with the plethora of to provide individual support around behaviour
voluntary sector services’ can be ‘very challenging’ change. Issues around contracting and provision
for inner-city general practitioners. Without a are not simply a matter of defining roles, they
mediating mechanism, better integration is touch on fundamental debates about the bound-
unlikely to happen spontaneously and there is aries of state (free) provision, voluntarism and
evidence that project workers can play a key the role of communities in health (Lewis, 1999).
bridging role (Peckham et al., 1998; Fawcett and There is a small but significant risk for public
South, 2005). While the CHAT scheme has been health that the greater integration of voluntary
pioneered in what might be termed traditional and community sector in primary care will result
general practice, social prescribing could be in less emphasis on advocacy and campaigning
embedded within more radical community devel- (Milligan, 1998).
opment approaches within primary care (Fisher,
2001; Crowley et al., 2002). There is certainly
potential to build health alliances but further Conclusion
research is needed to examine whether social pre-
scribing leads to changes in health professionals’ Traditionally, many community health initiatives
knowledge, attitudes and use of the community and have developed outside primary care settings
voluntary organisations. and the challenge is to integrate public health
Primary Health Care Research & Development 2008; 9: 310–318Can social prescribing provide the missing link? 317
into mainstream primary care. Social prescribing Bromley NHS Primary Care Trust. 2001: Penge & Anerley
offers a way to address some of the wider deter- Community Health Project. ‘‘A social pill for every ill’’: seminar
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It deals with the paradox that people use primary Anerley Community Health Project, NHS Beacon Services.
Brown, M., Friedli, L. and Watson, S. 2004: Prescriptions for
care for social needs, despite the fact that those
pleasure. Mental Health Today, June, 20–23.
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the health system should be viewed as an oppor- care and public health – a necessary relationship. Health
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